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My mother has approached late stage dementia. She has fallen and needed emergency lift assist twice this month. My father has provided 100% care for her for the last five years. He now has pneumonia and I can tell he is exhausted and needs help. But is being stoic and stubborn insisting that he can continue to care for her while trying to recover.
I am calling her primary care for a hospice reference and assessment. What else should I request from the primary and hospice?
I am well versed with POA and financial aspects for long term care facilities but home care is a new beast to tackle. I am POA for my mother but I am including my fathers wishes and best interest as well. He really wants to allow her to remain home and not be separated from each other. They just celebrated 59 years of marriage and I can't fathom me having to separate them now.
Any advice is very appreciated. It is avery emotional time and I am trying to remain realistic and my focus isn't at its peak so if I have omitted any information that may help with answers I will try my best to add informationas asked.

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When my dad chose home hospice he immediately received a hospital bed with a pressure relieving mattress, along with nearly endless medical and home health supplies. All Depends, bed pads, bedside commode, meds, etc came quickly. This would be a huge help to you and won’t need asking for, it is standard. There will be regular nurse visits, an aide for bathing, and chaplain visits if wanted. I relied on our hospice nurse for much needed advice at many different hours. I think you’ll find it a relief and wish you much rest and peace during such a hard time
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Reply to Daughterof1930
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AMZebbC Oct 21, 2025
Can I ask what the assessment for hospice entailed? My mother sleeps about 23 hours a day, very few communication words, no ability to perform ADL and can not walk. I wonder what criteria os needed for hospice?
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You need 3 caregivers at 8 hours each shift. Good luck.
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AMZebbC Oct 21, 2025
While that is the norm for fully mobile dementia patients. Is it still a requirement for bed bound patients in home hospice?
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First you do NOT have to get a hospice referral from your mothers PC. You just pick up the phone and call the hospice agency of your choice and ask them to come out and do an assessment.
From the sounds of it your mother would most certainly qualify for their services. Though keep in mind that to start a nurse will come out only once a week to check your mothers vitals and aides will come about twice a week to bathe her. Other than that the rest of your mothers care will be on you, your father or any hired aides you may need.
Of course hospice will supply any and all needed equipment, supplies and medications all covered under your mothers Medicare, but 99% of her care will still fall on you and your father.
I think that now you must do what is best for all involved, which may include having your mother placed in a nursing facility where you all can get back to just being her loving family members instead of her overwhelmed and burned out caregivers.
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AMZebbC Oct 22, 2025
Thank you. I was not aware we didnt need a referral.

I am acutely realizing that a LTC facility may be better. But I need to explore the resources that may keep her at home for my fathers benefit. He is very realistic but love, devotion and obligation is overshadowing his thought process. I need to do due diligence and give my father the evidence that long-term facility is best for mom for him to see I am not jist dumping her there. It has been a long journey for them.
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Hospice care has been very helpful for my mom and our family, but it is far from being 24/7 (or even many hours per day) care. It can be especially difficult to find appropriate care when the main danger for the "patient" (your mom, in your situation) is that she is falling down. Even with someone around a lot of the time, it can be hard to prevent all falls. I suggest that you start by thinking hard about whether your dad is likely to recover sufficiently to go back to being the primary caregiver. At his age and with his illness, that might be unrealistic to expect.
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AMZebbC Oct 21, 2025
I believe he will recover fully. He was smart enough to go to the doctor early with symptoms and has been on antibiotics with significant improvement.

The falls have occured when she has been walking with a walker from couch to bed. I truly believe she is now going to be bed ridden. She hasn't made amy attempt to get out of bed for weeks. Unfortunately my father was insistant that she have movement and that contributed to her fall/collapsing to the ground.
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Bed bound patients need 24/7 care. Long term care is your best bet to give your dad some much needed rest and your mom the care she needs. Start looking tomorrow. Hospice can still work with LTC.
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The decision may not be up to you or rather your Dad. Hospice will come to their home to do an assessment. It will mainly focus on mom as to her abilities and what she is doing every day to maintain her best health status. But they will also evaluate the overall home situation. ((A good hospice agency will be realistic with families on this. But there will always be those who aren’t as the capitation rate that Medicare pays hospice is pretty good.))

So the assessment will be looking at her ADL abilities, how her medications are done and if she seems lucid and cognitive of where she is, what the day is, etc. type of details. However in addition to all this, they will look at the condition of the home (that it’s condition is sanitary and safe) and who the individual(s) will be as the person required to be there all non hospice time as her caregiver as per In Home Hospice regulations. Hospice is a Medicare Part A benefit and a requirement under Medicare is there needs to be an adult caregiver present for all times other than when the hospice staffers come to see your mom at home. The same requirement is there for those who are in PACE too as it is primarily paid by Medicare.

Should your Dad appear not to be able to physically do what’s necessary for him to be her caregiver for all the rest of the time when hospice is not there, the agency can put in their report something like “for the safety and security of the patient, we are recommending placement in a nursing facility. As such we are unable to meet the clients needs”. If during the assessment, there are questions regarding your parents fire escape plan, that is a red flag that they have serious concerns about him all by himself being the only go-to caregiver for her. If she will be needing a Hoyer lift and he can’t physically do what needed to assist her to get her in & out, that’s another red flag. Ditto for him being able to bathe & Hygiene her if she is bedfast. Hospice tend to want at least 2 persons involved with caregiving and on a schedule. They want the caregivers to be able to have their own time and be able to get their rest. If the person is way younger (like in their 40’s / 50’s but terminal cancer) and can do their medications, hospice can be ok with a caregiver that is not FT & always there. But your mom sounds like needing always 24/7 oversight.

Now if the goal really is she is best off in a facility, then your expressing your own concerns about dads limitations to be solo caregiver and that he’s recovering from pneumonia and that you cannot yourself be an in their home caregiver…. Well this could work in your favor to get mom into a facility….. that In Home Hospice really isn’t feasible option if it’s just Dad. But if you do want to try In Home for a while, I’d really suggest that they plan on hiring a caregiver to come in 3-4 days a week for the minimum 4-5 hr block that most healthcare companies require. And you have this info lined up and drop into place once hospice starts.

If your mom is completely bedfast, realistically in my experience, it takes a team to provide the bathing, dressing, hygiene, almost inevitable wound care, and companionship she needs. My mom was on hospice and 100% bedfast 18 l…o..n…g months (fell forward pulling her wheelchair to go to activities at her NH), the bathing was a 2 - 3 person team in a shower room with mom in a geribathe chair. It was pretty amazeballs to watch them, there was no way that I solo on my own could ever bathe her to the degree that they did.
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AMZebbC Oct 27, 2025
@igloo Thank you for this detailed post. It is looking like a in facility hospice setting is better for my mother. It is a matter of getting the plan in motion. My mothers decline in addition to my uncles needs is becoming a overwhelmig task. So much that my husband and I are starting to plan NOW, before retirement.
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You can call hospice directly to do an assessment. You don't need a referral.
Hospice will pull your parent's records from the PCP to evaluate.
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The RN will come to the house. Take vitals. The RN will ask Mom questions.
The medical staff pulls Mom's electronic records and the Doctor back at the hospice will make the final decision about entry into hospice.
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If he wants her to remain at home hire a CNA for the daytime.

CNA's do end of life care all of the time.
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Someone posted the question: How to get rid of urine smell in laundry?
I use 1and 1/2 cups of white distilled vinegar when washing, especially for Grandma she sometimes wets in her clothes. Vinegar kills germs and sanitizes
your clothes. Give it a try, you will like it. Answer back and let me know what you think.
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